Request an Appointment

Please complete the form below to request an appointment.

First Name(required*)

Last Name(required*)

Birth Date(required*)

Sex(required*) Male
Female

Are you a new patient?(required*) Yes
No - Current patients can schedule appointments in MyChart

Street Address

City

State

Zip Code(required*)

Phone(required*)

This is my(required*)

How would you prefer we contact you? Phone
Email

How did you hear about us?

Disclaimer

Emergency requests cannot be processed through this form. If you are experiencing a medical emergency, please dial 911 or go immediately to the nearest emergency room.

This form is a secure form and the information you provide will be kept confidential.

To schedule office appointments:

This form should be used for non-urgent appointment requests only. If you prefer to speak with someone immediately please call your doctor or Mercy Medical Center at 410-332-9000.

If you are submitting this request during non-business hours, please allow additional time for a representative to contact you.

To schedule surgery:

Please call your doctor or the Mercy scheduling center during regular business hours. This form cannot be used to schedule surgical procedures.